Prospective Evaluation for Hybrid Cardiac Procedures
Overview
- Phase
- Not Applicable
- Intervention
- Not specified
- Conditions
- Left Main Coronary Artery Disease
- Sponsor
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Enrollment
- 134
- Locations
- 1
- Primary Endpoint
- Number of participants with stroke
- Status
- Completed
- Last Updated
- 8 months ago
Overview
Brief Summary
Multidisciplinary team-approach in order to offer personalized treatments represents the emerging mainstream in cardiovascular medicine. "Hybrid operative rooms" allow to offer selected heart-disease patients truly "tailored" operations.
This study wants to evaluate the effectiveness and safety of Hybrid Procedures in cardiac patients in three subgroups of patients:
- Hybrid coronary revascularization strategy (coronary by-pass + PCI);
- Hybrid valve and coronary disease correction (combination of surgical valve replacement and PCI);
- Hybrid coronary and carotid artery disease treatment (combination of coronary by-pass and carotid stenting).
The investigators hypothesize that morbidity might be reduced by 50% in hybrid procedures group as compared with predicted Society of Thoracic Surgery (STS) score.
Detailed Description
Cardiovascular medicine is actually evolving fast and multidisciplinary team-approach in order to offer personalized treatments represents the emerging mainstream. The possibility to realize combinations of treatments traditionally available only in the catheterization laboratory and in the operating room represent the rationale for "hybrid operative rooms" facilities allowing to offer selected heart-disease patients truly "tailored" operations. Such "Hybrid" management strategies usually combine transcatheter techniques and surgery (often minimally invasive) in order to combine the reduced invasiveness of the former with the effectiveness of the latter. Common examples of surgical and transcatheter combinations are: hybrid revascularization performed with coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI); combined heart valve and coronary disease treated with valve surgery and PCI; combined endo- and epicardial ablation of atrial fibrillation; thoracic aneurysms treated with endovascular stenting and surgical debranching of the arch; carotid artery stenting along with CABG. Given the relatively recent development of these techniques, indications and patient selection are yet to be defined and a productive collaboration between surgeons and interventional cardiologists is of paramount importance. Aim of the study is to evaluate the effectiveness and safety of Hybrid Procedures in cardiac patients. Specifically, three subgroups will be analysed: * Hybrid coronary revascularization strategy (HCR, coronary by-pass + PCI); * Hybrid valve and coronary disease correction (combination of surgical valve replacement and PCI); * Hybrid coronary and carotid artery disease treatment (combination of coronary by-pass and carotid stenting). The local Heart Team (cardiac surgeon, interventional cardiologist, clinical cardiologist and anaesthetist) will decide which patients will be referred for hybrid treatment. Typically, this happens when the Heart Team feels that hybrid treatment could reduce the overall risk of a combined procedure. The patient population consists of adult patients with: * Multi-vessel coronary artery disease (CAD) involving the left main and/or the left anterior descending artery with indication for revascularization; * Severe, symptomatic valvular disease and CAD with indication for revascularization; * Significant unilateral carotid stenosis and CAD with indication for revascularization. In a previous data review board on the Heart Team activity, we recognized that 10% of discussed patients are referred for hybrid procedures (HP) and that observed operative mortality was strongly lower than that predicted by STS and EuroSCORE (2.5% versus 10.1% and 5.9%, respectively). Morbidity was not prospectively investigated. For sample size estimation, the investigators hypothesized that Morbidity might be reduced by 50% in HP group as compared with predicted STS. The mean expected STS morbidity estimated in the study population is 32.57%. Accordingly, a total number of 111 patients with an alpha error of 5% and a beta error of 20% has been calculated to be needed to test this hypothesis.
Investigators
Dr. Bruno
Clinical Professor
Fondazione Policlinico Universitario Agostino Gemelli IRCCS
Eligibility Criteria
Inclusion Criteria
- •Signed informed consent, inclusive of release of medical information
- •Age ≥ 18 years
- •CAD with indication for revascularization
- •Coronary anatomy as follows:
- •Multivessel-CAD involving the left anterior descending (LAD) (proximal or mid) and/or the left main (LM) (ostial, mid-shaft or distal) with at least one further epicardial coronary artery requiring treatment (LCX or RCA), OR
- •Single vessel disease involving the LAD and a major diagonal, both requiring independent revascularization with at least one stent
- •Severe aortic stenosis/insufficiency and/or mitral stenosis/insufficiency requiring surgery, with CAD (involving one or more vessels), suitable for PCI
- •CAD with indication for revascularization with severe unilateral carotid stenosis (\>85%)
- •Ability to tolerate, and no plans to interrupt dual antiplatelet therapy (DAPT) for:
- •At least 6 months in presentation was stable CAD,
Exclusion Criteria
- •Previous cardiac surgery of any kind
- •Previous thoracic surgery involving the left pleural space (if a left thoracotomy approach is planned)
- •Complicated or unsuccessful PCI within 30 days prior
- •Total occlusion (TIMI 0 or 1 flow) of the LM or LAD
- •Cardiogenic shock at time of screening
- •Any prior lung resection
- •End-stage renal disease on dialysis
- •Extra-cardiac illness that is expected to limit survival to less then 5 years
- •Allergy or hypersensitivity to any of the study drugs or devices used in protocol
- •Patient unable to give informed consent or potentially noncompliant with the study protocol, in the judgement of the investigator
Outcomes
Primary Outcomes
Number of participants with stroke
Time Frame: 6 days after operation
Rapid onset of a new neurological deficit attributed to an obstruction in cerebral blood flow and/or cerebral hemorrhage with no apparent non-vascular cause (e.g., trauma, tumor, or infection) that i) persists beyond 24 hours, or ii) less than 24 hours if: a) associated with infarction or hemorrhage on an imaging study, or b) treated with pharmacologic or mechanical intervention, or c) results in death.
Number of participants with major morbidity or operative mortality
Time Frame: 6 days after operation
A composite endpoint defined as any of the outcomes listed in the first six rows of this list
Number of participants with deep sternal wound infection
Time Frame: Diagnosis within 30 days of the operation or >30 days after procedure but during hospital stay for surgery.
Deep sternal wound infection or mediastinitis (according to Centers for Disease Control (CDC) definition)
Number of participants who undergo reoperation
Time Frame: 6 days after operation
Reoperation for bleeding/tamponade, valvular dysfunction, graft failure, aortic reintervention, or other cardiac reason.
Number of participants with renal failure
Time Frame: 6 days after operation
Acute or worsening renal failure resulting in one or more of the following: 1. Increase of serum creatinine to ≥ 4.0 with an increase of at least 0.5mg/dl or 3x most recent preoperative creatinine level. 2. A new requirement for dialysis postoperatively.
Number of participants with prolonged ventilation > 24 hours
Time Frame: 25 hours after operative room exit.
Prolonged postoperative pulmonary ventilation \> 24.0 hours.
Number of participants with long stay
Time Frame: 15 days after operation
Patient length of stay \> 14 days. Failure to be discharged within 14 days of surgery
Number of participants with short stay
Time Frame: 6 days after operation
Patient length of stay \< 6 days. Discharged alive and within 5 days of surgery
Secondary Outcomes
- Health Status through quality of life assessment.(30 days post procedure and 12 months)
- Bleeding(30 days post procedure and 12 months)
- Rate of one or more additional adverse event.(30 days post procedure and 12 months)
- Health Status through angina assessment.(30 days post procedure and 12 months)
- Cardiovascular events(30 days post procedure and 12 months)
- Cost-effectiveness(12 months post procedure)